Provider Demographics
NPI:1649280058
Name:THANEPOHN, DENISE LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:LYNN
Last Name:THANEPOHN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-3219
Mailing Address - Country:US
Mailing Address - Phone:907-272-2557
Mailing Address - Fax:907-274-4932
Practice Address - Street 1:1345 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3219
Practice Address - Country:US
Practice Address - Phone:907-272-2557
Practice Address - Fax:907-274-4932
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOP0096Medicaid
AK00WCKFRCMedicare ID - Type UnspecifiedMEDICARE
AKOP0096Medicaid
AK0397780001Medicare NSC